26461 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEOILD)♦11"'LECTR PERMIT NO. 26461
SIO NO APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLIGTIONSUBMIITALDATE
LL UNIT N LOT 0
OWNERS NAME: PHONE CONTRACTOR'S NAME LIC NQ
_ y NIC CONTROL N
ARCIIITF;C'I'll'NGINH.ER: LIC O' ADDRESS: ❑
S
CONTACT: PHONe:
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT ft`M MECH
PFRMRISSUANCE El El JQ 0
LICENSED CONITtACIIfR.S DECLARATION APPLIANCES-RESIDENTIAL III����
py)i Ihertby uffrmthu l 3 a terncJuNapund Foauaf Chnpl and mmucinQ with
JOB DESCRIPTION
+�+00 full f n mtf a f,,n. on J of de Busiau and Prvfaiau Code utd my li-oue u w PANELSOut-
��� full face ud effect.
IS„ZW I.icrnrc Cluu Lic.N UP TO SW AMPS Fall r D.
ti Q y Dart - Cotwaa 101-1000 AMPS ZJ
LQ�z ARCHITECTS DECLARATION OVER 1000 AMPS SO.FT.FLOOR AREA
oz-n InrdmlvWmrPlmusn.ubenvduPuNicrecnN.. r
Fundal SIGNS ELECTRICAL
9Qy ,J Licenvcd Pu,fi.iorul
rG < OWNER-BUILDER DECLARATION SPEC1ALCBICUITh9SC _
Oa[- I hereby all tout 1 mn eaernp from the Costen'.Liaise Lew for the .. - c. -
t Som following rtawn.(SmianIW LS,Bua' -- ard Profwiau cndc.Mynityorrnuoty TEMP.METER OR PoIEw _
�o, whim on a o,i a pmnlhm oautrucl also,ionl demolish,m repair my mucttve (,//—/1
`�>-� prig to in iswnrtn,also rtquim tic epplirntfa.uchpmrdt tofk•slgad statcmou POWER DEVICES 2
ty s 0o Pont he in;lie Purvunt to th povuiav of de Contractals l Law(ClupenDATE
d 9(cmmnencing with Seclion'1000)ufdvieion 3.fdo Business end P,o lass Code) SWIMMING P001-ECB IC VALUATION
� y aPon hei.,a,mdthetefmn.rld butt'(mBe.Ilegdeaerrtpti--,1iolutionof
�- Smion]0313 ppliem pmJly OUTLETS
�ZQ by myldotto,(m).it.ubject.the tto•civil of
not macthml fvc hunWdddWa(SSoO). NEW RISIDFNTIAL ELECTR _SQ.FT.pw ❑ I,uownmaflhcptLcnY.amY rmpayenwitM1 wngn arthirwlccompavadon, SWRILS TYPECONSTRGCTIONI
4a will Jn Wcwnrk,erWe:Tho Cmei.toc,n Lo a w do,ror We(Sec.1014,Bu.ula
and Pmfea.iona Code:The Conuxta'a Liatue law doq oot apply to m vwrlen of
ownl eou whobuillsyeorirmmvn Wrrmn,.rd sob Masuch woo hinuclforWmughhf,
mploe,pmviddtM1mwchinlprnvenxnuurt nainlenJdmufferd fasele.IL OCU. ROUP RES.UNITS
bwever,We Wii,bng m impmv,ment u sold within one yeuofmrnpleoau,JI,own,r-
buJdef.W hath
ve e burdenof poving toss he did ra build a bryevve fa purpox a TOTAL:
aak.).
❑ I.ssow roflhcpr<pay,emeeclusivelycnniefigwitM1ll..dcon tc, QTY, PLUMBING PERMIT ICF, I DZONI, APN
uutruu the ptojtn(Sec 9040.Benin.and Profe .Code)The Cotdracmaa
licenx taw Jou rotapplY tomvwrtn Mpopeny sono bund.aimporodrveor4 ertd I'll ISSUANCE
who—wets fa. Oi pojeOs with.eontr.mur(s)lion Putsoutnmth Conv.ctors ALIHIt-DRAINR VENT-WATER fit)
Llcctme Lew. (' FEE SUMMARY
❑ 1 em uemp uMc Sec. B k P C for thH een.on BACK FLOW PROTECT.DEVICE
SANITARY Y N
bwrcr Dene DRAINS-FLOOR,ROOF,AR BA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION
` syo�N N
Ihertby aft Wer l hove a c,nif•` m
•,ofcomt to rf-Ia nure, a aniftcuc of SCHOOL TAX RECHTPf#
W S a
Cnpenumon lovmee a acerufidaopy WereoflSee 3m,lC.)which Fl%TURFS-PER'IRgP PARK FEE TN
Pu,71"em fe'a t' p it GAS-EA.SYSTEM.I INC.4 OUTIBUILDINGDVISIIOON
mFFCS
Copany n� grlRll ET5 GAS-FA SYSTEM-OVER 4(EA) PLANCHECK FE£
Carifkd copy a hrtlry rumided
Ceoifd copy to;fluid with Oc city ins,extion divialm. GREASFANDUSTRI.WASTE INTFRCIi-PYR
GRADING IPE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Dus section rad not be cmnpleted ifdc pmmit is fxone htndred dollm.(SDID) SEWER-SANITARY-STORM G.NOPE. PNERGY ITR
m lis+)
I certifythatw Ju pe+forrwrce of d¢work fm which Poi.permithl•^I"I WATER HIATIER W/VEJNTj[i FiCIR
not emP,any puvon in any mmmm so m to bcmrte abject to the Workcai PAID
C.npenwionlawaof Glifania Date WATER SYSTFINfREAIING Dutc Rccei t
O z Applicant
Z O NOTICE TO APPLIGM':If.afta meting lds Caul of Eaentpdon,you abotJd NEW RESIDENTIAL Pl SQ.Ff. TOTAL
T/1 became sobje n o,the Woidda Canpmvtim pori.iae of We labor Cade,you muss
aforthwith amply with such pmririat.or In,peon it.hatl be deemed rtvokd. BUILDING P:F.
d (] CONSTRUCTION LENDING AGENCY SEISMIC FIE
I hereby affirm tout there u.mruvemJon Imding.gency for the pmf000 oe of
U O be,work for which Ws permit is iuued(S 3897,Cr,C.) TOTAL EJ.HCITtIC Min
0 V lsder'.N. PLUMBING FEE
j Dxuld.Addtas QTY. MECHANICAL PERMIT FEE
1 ecnify Bout 1 h.ve read this apPlicnion and ewe dw the.hove irdomuam i.
curmxt.IagrtemcomplYwilhdlcityud ctwlty cedEur<aeM au¢6w ahtinglo PERMIT ISSUANCT: MECHANICAL FEE
I" huildingrnnur,aion,anJ hrtby nathaix repr,amwlro of Poi.city toulkrupon the
U z above-mmtiodedi popaty fa ii,eetion putposa. ALTER OR ADD TO MECH. CONSfRUCIONTAX
(We)agree to save,indamlify mI keep hml the City of Cularirlo.,moss
.. lubilitin,judgmmta,coni"ex,,ma which may in anyways g.instyyy```d Cty AIRHANDLINGUNITITOIgf00CFM)
in nm of granting of thiv permit �r /�
1/C�•�/ /G</ AIR HANDLING UNIT(OVER 10,1x10 CFM)
Signmwcof Applion,/Contrecor / DmEXIIAUSTIIOOD(W/DUC) PAID
HAZARDOUS MADRIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Reaiyt0
Will th yro nut a future building oaniould dac of ou le hoo doua mutcrial
u Jcfn d by the Cupen in.Municipal Cade,Ctapm 9.11,and W,Hcahh and Stdl HEATING UNIT(OVER IOO,t00 BTU) 'DOTAL:
Cdc,S,di EYu ❑No LE l 25531(g1
❑ VENTILATION FAN(SINGRPSID)
Will the applicant a fuwrt building rccupant uta eRuirnxnt a dwica whicM1 emit
BOILER-COMP(JIIP OR IUT,IXq B'N) ISSUANCE DATE
hexrdous to,emlmdtwnts ns defined by the B.,Ates An Quality M.rcgement BOILER-COMP(OVER 100,1x0 BTU)
Di mal
❑Yo ❑No NEW RESIDENTIAL MECH. SQ.FT.
I here tad the hiss d dt makrinlx teNuirtnwnts uo a Clarycr 695 of th P A 1 D
Ci,ifmil Health k S.rety cad,. o,e.1 1,x,vSJJ and],uosi 1 undcntvd than V`
if Rhobuildingdais not curmlJY nave•.tic Jut it Is my rupanibilityerutty We
Oc a.W of th nbem eta which mun h mm p err to �nm e ata Gertifnte M JUN 13 A
Occupuncy.
Owns aembrixd vgmt Dete TOTAL-
OFFICE
OTALOFFICE